Method and device for performing cooling- or cryo-therapies for, e.g., angioplasty with reduced restenosis or pulmonary vein cell necrosis to inhibit atrial fibrillation employing tissue protection

ABSTRACT

An enhanced method and device are provided to treat atrial fibrillation or inhibit or reduce restenosis following angioplasty or stent placement. A balloon-tipped catheter is disposed in the area treated or opened through balloon angioplasty immediately following angioplasty. The balloon, which can have a dual balloon structure, may be delivered through a guiding catheter and over a guidewire already in place. A fluid such as a perfluorocarbon flows into the balloon to freeze the tissue adjacent the balloon, this cooling being associated with reduction of restenosis. A similar catheter may be used to reduce atrial fibrillation by inserting and inflating the balloon such that an exterior surface of the balloon contacts at least a partial circumference of the portion of the pulmonary vein adjacent the left atrium. In another embodiment, blood perfusion is performed simultaneously. In another embodiment, tissue contacted by the cryoablation catheter, undesired to be ablated, is protected against damage by a separate heating step.

CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application is a continuation-in-part of U.S. patentapplication Ser. No. 09/787,599 filed Mar. 21, 2001, entitled “Methodand Device for Performing Cooling-or Cryo-Therapies for, e.g.,Angioplasty with Reduced Restenosis or Pulmonary Vein Cell Necrosis toInhibit Atrial Fibrillation” which is a continuation-in-part of U.S.patent application Ser. No. 09/516,319, filed Mar. 1, 2000, entitled“Method and Device for Performing Cooling-or Cryo-Therapies for, e.g.,Angioplasty with Reduced Restenosis or Pulmonary Vein Cell Necrosis toInhibit Atrial Fibrillation” which is a continuation-in-part of U.S.patent application Serial No. 09/052,545, filed Mar. 31, 1998, entitled“Circulating Fluid Hypothermia Method and Apparatus” and U.S. patentapplication Ser. No. 09/215,038, filed Dec. 16, 1998, entitled“Inflatable Catheter for Selective Organ Heating and Cooling and Methodof Using the Same”. This application is also continuation-in-part andutility conversion of Provisional Application Serial Nos.: 60/272,550filed Mar. 1, 2001, entitled “Method and Apparatus for Inhibiting TissueDamage During Cryo-Ablation”, and 60/273,095 filed Mar. 2, 2001,entitled “Annular Ring Balloon for Pulmonary Vein Cryoplasty”, all ofthe above are incorporated herein.

CROSS-REFERENCE TO MICROFICHE APPENDIX

[0002] (none)

BACKGROUND OF THE INVENTION

[0003] Balloon angioplasty, or the technology of reshaping of a bloodvessel for the purpose of establishing vessel patency using a balloontipped catheter, has been known since the late 1970's. The procedureinvolves the use of a balloon catheter that is guided by means of aguidewire through a guiding catheter to the target lesion or vesselblockage. The balloon typically is equipped with one or more markerbands that allow the interventionalist to visualize the position of theballoon in reference to the lesion with the aid of fluoroscopy. Once inplace, i.e., centered with the lesion, the balloon is inflated with abiocompatible fluid, and pressurized to the appropriate pressure toallow the vessel to open.

[0004] Typical procedures are completed with balloon inflation pressuresbetween 8 and 12 atmospheres. A percentage of lesions, typically heavilycalcified lesions, require much higher balloon inflation pressures,e.g., upward of 20 atmospheres. At times, the balloon inflationprocedure is repeated several times before the lesion or blockage willyield. The placement of stents after angioplasty has become popular asit reduces the rate of restenosis.

[0005] Restenosis refers to the renarrowing of the vascular lumenfollowing vascular intervention such as a balloon angioplasty procedureor stent insertion. Restenosis is clinically defined as a greater than50% loss of initial lumen diameter. The mechanism or root causes ofrestenosis are still not fully understood. The causes aremultifactorial, and are partly the result of the injury caused by theballoon angioplasty procedure and stent placement. With the advent ofstents, restenosis rates have dropped from over 30% to 10-20%. Recently,the use and effectiveness of low-dose radiation administeredintravascularly following angioplasty is being evaluated as a method toalter the DNA or RNA of an affected vessel's cells in the hope ofreducing cell proliferation.

[0006] Another cardiological malady is atrial fibrillation. Atrialfibrillation is common following various cardiac surgeries, e.g., valvesurgery. Atrial fibrillation refers to very rapid irregular contractionsof the atria of the heart resulting in a lack of synchronization betweenthe heartbeat and the pulse. The irregular contractions are due toirregular electrical activity that originates in the area of thepulmonary veins. A proposed device, currently under development, fortreating atrial fibrillation is a balloon filled with saline that can beultrasonically agitated and heated. This device is inserted in thefemoral vein and snaked into the right atrium. The device is then pokedthrough the interatrial septum and into the left atrium, where it isthen angled into the volume adjoining the suspect pulmonary vein withthe left atrium.

[0007] Research in atrial fibrillation indicates that substantiallycomplete circumferential necrosis is required for a therapeutic benefit.The above technique is disadvantageous in that circumferential portionsof the tissue, desired to be necrosed, are not in fact affected. Othertechniques, including RF ablation, are similarly inefficient. Moreover,these techniques leave the necrosed portions with jagged edges, i.e.,there is poor demarcation between the healthy and the necrosed tissue.These edges can then cause electrical short circuits, and associatedelectrical irregularities, due to the high electric fields associatedwith jagged edges of a conductive medium.

[0008] The above technique is also disadvantageous in that heating isemployed. Heating is associated with several problems, includingincreased coagulum and thrombus formation, leading to emboli. Heatingalso stimulates stenosis of the vein. Finally, since tissues can onlysafely be heated to temperatures of less than or about 75° C. -85° C.due to charring and tissue rupture secondary to steam formation. Thethermal gradient thus induced is fairly minimal, leading to a limitedheat transfer. Moreover, since heating causes tissues to become lessadherent to the adjacent heat transfer element, the tissue contact withthe heat transfer element is also reduced, further decreasing the heattransfer.

[0009] Another disadvantage that may arise during either cooling orheating results from the imperfections of the surface of the tissue ator adjacent to the point of contact with the cryoballoon (in the case ofcooling). In particular, surface features of the tissue may affect thelocal geometry such that portions of the balloon attain a bettercontact, and thus a better conductive heat transfer, with the tissue.Such portions may be more likely to achieve cell necrosis than otherportions. As noted above, incomplete circumferential necrosis is oftendeleterious in treating atrial fibrillation and may well be furtherdeleterious due to the necessity of future treatments. Accordingly, amethod and device to achieve better conductive heat transfer betweentissue to be ablated and an ablation balloon is needed.

[0010] A further disadvantage with prior systems arises from thetemperature of the components. In particular, it is preferable if onlythe atrial tissue is exposed to cryogenic temperatures. However,occasionally, other tissues is exposed, such as the tissue at or nearthe insertion site of the catheter. Thermal tissue damage mayoccasionally occur.

[0011] In some situations, pulmonary vein cryo-ablation for treatment ofatrial fibrillation may require long occlusion times, such as greaterthan five minutes. In such situations, there is a risk of stroke, whichis clearly a disadvantageous result.

[0012] Prior attempts to remedy this included a perfusion balloon thatfacilitated flow through the catheter shaft. This design suffered fromvarious drawbacks, such as the necessity of bringing the blood intodeleteriously close contact with the refrigerant, and the insufficiencyof space to provide unrestricted blood flow through the catheter. Inanother prior approach, a helical or star-shaped balloon was used whichwas self-centering. This design also suffered from various drawbacks,such as unequal ablation around the circumference.

SUMMARY OF THE INVENTION

[0013] The present invention provides an enhanced method and device totreat atrial fibrillation or to inhibit or reduce the rate of restenosisfollowing angioplasty or stent placement. The invention is similar toplacing an ice pack on a sore or overstrained muscle for a period oftime to minimize or inhibit the bio-chemical events responsible for anassociated inflammatory response. An embodiment of the inventiongenerally involves placing a balloon-tipped catheter in the area treatedor opened through balloon angioplasty immediately following angioplasty.A so-called “cryoplasty” balloon, which can have a dual balloonstructure, may be delivered through a guiding catheter and over aguidewire already in place from a balloon angioplasty. The dual balloonstructure has benefits described below and also allows for a more robustdesign. The balloon is porous so that an amount of ablation fluid isdelivered to the tissue at the ablation site.

[0014] The balloon may be centered in the recently opened vessel withthe aid of radio opaque marker bands, indicating the “working length” ofthe balloon. In choosing a working length, it is important to note thattypical lesions may have a size on the order of 2-3 cm. In the dualballoon design, biocompatible heat transfer fluid, which may containcontrast media, may be infused through the space between the dualballoons. While this fluid does not circulate in this embodiment, onceit is chilled or even frozen by thermal contact with a cooling fluid, itwill stay sufficiently cold for therapeutic purposes. Subsequently, abiocompatible cooling fluid with a temperature between about, e.g., −40°C. and −60° C., may be injected into the interior of the inner balloon,and circulated through a supply lumen and a return lumen. The fluidexits the supply lumen through a skive in the lumen, and returns to therefrigeration unit via another skive and the return lumen.

[0015] The biocompatible cooling fluid chills the biocompatible heattransfer fluid between the dual balloons to a therapeutic temperaturebetween about, e.g., 0° C. and −50° C. The chilled heat transfer fluidbetween the dual balloons transfers thermal energy through the balloonwall and into the adjacent intimal vascular tissue for the appropriatetherapeutic length of time.

[0016] To aid in conduction, a small portion of the chilled heattransfer fluid between the dual balloons may contact the adjacentintimal vascular tissue for the appropriate therapeutic length of timedue to the porosity or microporosity of the outer balloon.

[0017] Upon completion of the therapy, the circulation of thebiocompatible cooling fluid is stopped, and the remaining heat transferfluid between the dual balloons withdrawn through the annular space.Both balloons may be collapsed by means of causing a soft vacuum in thelumens. Once collapsed, the cryoplasty catheter may be withdrawn fromthe treated site and patient through the guiding catheter.

[0018] The device may further include a source of chilled fluid having asupply tube and a return tube, the supply tube coupled in fluidcommunication to the supply lumen and the return tube coupled in fluidcommunication to the return lumen. The source of fluid may be coupled influid communication to a volume between the inner balloon and the outerballoon. The fluid may be a perfluorocarbon such as Galden fluid. Thefluid may also include contrast media.

[0019] In one aspect, the invention is directed towards a device andmethod to mitigate blood flow stasis during application of cryoablationtherapies. Perfusion during cryoablation minimizes the risk ofembolization of a clot, leading to stroke or myocardial infarction, andfurther minimizes the freezing of blood.

[0020] In yet another aspect, the invention may be used in aprophylactic sense, i.e., may be employed following cardiac surgeries,such as valve surgery, to prevent a case of atrial fibrillation thatmight otherwise occur.

[0021] In yet another aspect, the invention is directed towards a deviceand method to limit tissue damage at, e.g., the site of insertion intothe patient's body, the atrial septum, and so on. Embodiments of thedevice may include a source of warmed fluid at circulates at or adjacentthe site of insertion, a resistive heater employed at or adjacent thesite of insertion, or other similar devices.

[0022] In a further aspect, the invention is directed to a device totreat tissue while preventing tissue damage to adjacent tissue,including an ablation catheter; an introducer sheath for the ablationcatheter, the introducer sheath at least partially contacting tissue tobe protected; and a heater disposed adjacent or within the introducersheath, the heater thermally coupled to the tissue; and a control unitfor the heater.

[0023] Variations of the invention may include one or more of thefollowing. The heater may be a resistive heater or may include an inlettube fluidically coupled to an interior of the introducer and at leastone outlet orifice disposed in the introducer. The heater may include aninlet sleeve with an input for a body fluid at a distal end of theintroducer sheath, where the inlet sleeve is fluidically coupled to aninterior of the introducer, and at least one outlet orifice disposed inthe introducer. The inlet sleeve may have an annular shape along aportion thereof. The resistive heater may be disposed on a sleeve, thesleeve concentric with the introducer sheath, and may be helically woundon the sleeve. The ablation catheter may further define a guidewirelumen; a supply lumen; and a return lumen. The guidewire lumen mayextend from a proximal end of the ablation catheter to a distal end ofthe ablation catheter. The device may further include a marker banddisposed on the ablation catheter to locate a working region of thedevice at a desired location. The device may further include a source ofcryo-ablation fluid having a supply tube and a return tube, the supplytube coupled in fluid communication to the supply lumen and the returntube coupled in fluid communication to the return lumen. Thecryo-ablation fluid, also called a cryofluid or a working fluid, may bea perfluorocarbon, Galden® fluid, DMSO, d-limonene, or the like. Thesource of the working fluid may include a gear pump for circulating thecryofluid, where the gear pump may be a radial spur gear pump, a helicaltooth gear pump, or the like.

[0024] In yet a further aspect, the invention is directed to a method oftreating atrial fibrillation while preventing tissue damage to theatrial septum, including: inserting a trocar wire capable of rupturingthe atrial septum from the femoral vein into the right atrium; forming ahole using the trocar wire in the atrial septum between the right atriumand the left atrium; inserting an introducer sheath into the hole, theintroducer sheath at least partially contacting the atrial septum;inserting a guide wire through the introducer sheath into the rightatrium and left atrium and further into a pulmonary vein; disposing anablation catheter over the guidewire into a volume defined by the jointof the left atrium and the pulmonary vein; flowing a cryofluid into aballoon disposed within the ablation catheter to ablate tissue adjacentthe joint of the left atrium and the pulmonary vein; and operating andcontrolling a heater disposed adjacent or within the introducer sheath,the heater thermally coupled to the atrial septum.

[0025] Variations of the method may include one or more of thefollowing. The operating and controlling a heater including providingpower to a resistive heater, or flowing a warming fluid into an inlettube fluidically coupled to an interior of the introducer sheath, andflowing the warming fluid out of at least one outlet orifice disposed inthe introducer sheath. The operating and controlling a heater may alsoinclude allowing a body fluid to flow in an inlet sleeve having an inputfor the body fluid at a distal end of the introducer sheath, wherein theinlet sleeve may be fluidically coupled to an interior of theintroducer, and allowing the body fluid to flow out of the at least oneoutlet orifice disposed in the introducer.

[0026] In another aspect, the invention is directed to a method ofperforming a cryosurgery while preventing tissue damage to the point ofinsertion, including: percutaneously forming an insertion hole in avessel of a patient; inserting an introducer sheath into the insertionhole, the introducer sheath at least partially contacting tissue at theinsertion hole; inserting a cryogenic catheter through the introducersheath; disposing the cryogenic catheter at a predefined location;flowing a cryogenic liquid into the cryogenic catheter; and operatingand controlling a heater disposed adjacent or within the introducersheath, the heater thermally coupled to the tissue at the insertionhole.

[0027] In a further aspect, the invention is directed to a method ofreducing atrial fibrillation, including: inserting a catheter at leastpartially into the heart, the catheter having a cold balloon, a portionof the balloon located in the left atrium and a portion of the balloonlocated in a pulmonary vein; and inflating the cold balloon with aworking fluid including d-limonene or DMSO such that an exterior surfaceof the cold balloon may be in contact with at least a partialcircumference of the portion of the pulmonary vein adjacent the leftatrium, the working fluid having a temperature in the range of about−10° C. to −100° C.

[0028] In yet a further aspect, the invention is directed towards amethod of reducing restenosis after angioplasty in a blood vessel,including: inserting a catheter into a blood vessel, the catheter havinga balloon; and inflating the balloon with a working fluid including DSMOor d-limonene such that an exterior surface of the balloon may be incontact with at least a partial inner perimeter of the blood vessel, theworking fluid having a temperature in the range of about −10° C. to−100° C.

[0029] In another aspect, the invention is directed towards a device toperform a cryo-ablation treatment while allowing blood perfusion,including: a catheter shaft having a supply lumen and a return lumen; anannular ring balloon fluidically coupled to the catheter shaft, theannular ring balloon having a fluid inlet coupled to the supply lumen,and a fluid outlet coupled to the return lumen, the fluid inletdisplaced relative to the fluid outlet, a plane of the annular ringballoon substantially normal to the catheter shaft when inflated; and asource of working fluid, the source having an inlet coupled to thereturn lumen and an outlet coupled to the supply lumen.

[0030] Variations of the device may include one or more of thefollowing. The fluid inlet may be displaced in a proximal directionrelative to the fluid outlet. The source of working fluid may include agear pump.

[0031] In a further aspect, the invention is directed to a device toperform a cryo-ablation treatment while allowing blood perfusion,including: a catheter shaft having a catheter supply lumen and acatheter return lumen; an annular ring balloon fluidically coupled tothe catheter shaft, the annular ring balloon having a balloon supplylumen coupled to the catheter supply lumen, and a balloon return lumencoupled to the catheter return lumen, an inlet for the balloon supplylumen displaced relative to an outlet of the balloon return lumen, aplane of the annular ring balloon substantially normal to the cathetershaft when inflated; and a source of working fluid, the source having aninlet coupled to the catheter return lumen and an outlet coupled to thecatheter supply lumen.

[0032] In yet a further aspect, the invention is directed to a method ofreducing atrial fibrillation, including: inserting a catheter at leastpartially into the heart, the catheter having an annular ring balloondisposed near a distal portion thereof, a portion of the annular ringballoon located in the left atrium and a portion of the annular ringballoon located in a pulmonary vein; and inflating the annular ringballoon with a working fluid such that an exterior surface of theannular ring balloon may be in contact with at least a partialcircumference of the portion of the pulmonary vein adjacent the leftatrium, the working fluid having a temperature in the range of about—10° C. to −100° C.

[0033] Advantages of the invention may include one or more of thefollowing. The invention inhibits or reduces the rate of restenosisfollowing a balloon angioplasty or any other type of vascularintervention. At least the following portions of the vascular anatomycan benefit from such a procedure: the abdominal aorta (following astent or graft placement), the coronary arteries (following PTCA orrotational artherectomy), the carotid arteries (following an angioplastyor stent placement), as well as the larger peripheral arteries.

[0034] When the invention is used to treat atrial fibrillation, thefollowing advantages inure. The cooled tissue is adherent to the heattransfer element and/or to the ablative fluid, increasing the heattransfer effected. Since very cold temperatures may be employed, thetemperature gradient can be quite large, increasing the heat transferrate. The ablative fluid that passes from the balloon to the tissue mayassist the heat transfer conduction and the ensuing cell necrosis.

[0035] In both embodiments, heat transfer does not occur primarily or atall by vaporization of a liquid, thus eliminating a potential cause ofbubbles in the body. Nor does cooling occur primarily or at all by apressure change across a restriction or orifice, this simplifying thestructure of the device. Thrombus formation and charring, associatedwith prior techniques, are minimized or eliminated.

[0036] Tissue, undesired to be ablated, may be subject to a separateheating step or element in order to prevent the same from exposure tothe cryoablative fluid.

[0037] Additional advantages will be apparent from the description thatfollows, including the drawings and claims.

BRIEF DESCRIPTION OF THE DRAWINGS

[0038]FIG. 1A shows a side schematic view of a catheter according to afirst embodiment of the invention.

[0039]FIG. 1B shows a cross-sectional view of the catheter of FIG. 1A,as indicated by lines 1B-1B in FIG. 1A.

[0040]FIG. 1C shows an alternate cross-sectional view of the catheter ofFIG. 1A, as indicated by lines 1B-1B in FIG. 1A.

[0041]FIG. 2A shows a side schematic view of a catheter according to asecond embodiment of the invention.

[0042]FIG. 2B shows a cross-sectional view of the catheter of FIG. 2A,as indicated by lines 2B-2B in FIG. 2A.

[0043]FIG. 3 shows a schematic view of a catheter in use according to athird embodiment of the invention.

[0044]FIG. 4 shows a cross-sectional view of the catheter of FIG. 3.

[0045]FIG. 5 shows an alternative cross-sectional view of the catheterof FIG. 3.

[0046]FIG. 6 shows an alternative cross-sectional view of the catheterof FIG. 3.

[0047]FIG. 7 shows a schematic view of the warm balloon of the catheterof FIG. 3.

[0048]FIG. 8 shows a side schematic view of a catheter according to afourth embodiment of the invention, this embodiment employing a porousballoon.

[0049]FIG. 9 shows a side schematic view of a catheter according to afifth embodiment of the invention, this embodiment employing a porousballoon.

[0050]FIG. 10 shows a first embodiment of a device that may be employedin the present invention to prevent tissue damage at, e.g., the point ofcatheter insertion into the patient's body.

[0051]FIG. 11 shows a second embodiment of a device that may be employedin the present invention to prevent tissue damage at, e.g., the point ofcatheter insertion into the patient's body.

[0052]FIG. 12 shows a third embodiment of a device that may be employedin the present invention to prevent tissue damage at, e.g., the point ofcatheter insertion into the patient's body.

[0053]FIG. 13 shows a first embodiment of a device that may be employedin the present invention to prevent tissue damage at, e.g., the atrialseptum.

[0054]FIG. 14 shows a second embodiment of a device that may be employedin the present invention to prevent tissue damage at, e.g., the atrialseptum.

[0055]FIG. 15 shows an embodiment of a device that may be employed inthe present invention to perform cryoablation while allowing blood flowduring an ablation procedure.

[0056]FIGS. 16 and 17 show more detailed views of the embodiment of FIG.15.

[0057]FIG. 18 shows a flowchart of a method for pre-outgassing a fluid.

DETAILED DESCRIPTION

[0058] Referring to FIG. 1A, a catheter 100 is shown according to afirst embodiment of the invention. The catheter 100 has a proximal end130 and a distal end 114. Of course, this figure is not necessarily toscale and in general use the proximal end 130 is far upstream of thefeatures shown in FIG. 1A.

[0059] The catheter 100 may be used within a guide catheter 102, andgenerally includes an outer tube 103, a dual balloon 134, and an innertube 122. These parts will be discussed in turn.

[0060] The guide catheter 102 provides a tool to dispose the catheter100 adjacent the desired location for, e.g., angioplasty or reduction ofatrial fibrillation. Typical guide catheter diameters may be about 6French to 9 French, and the same may be made of polyether blockamide,polyamides, polyurethanes, and other similar materials. The distal endof the guide catheter is generally adjacent the proximal end of the dualballoon 134, and further is generally adjacent the distal end of theouter tube 103.

[0061] The ability to place the guide catheter is a significant factorin the size of the device. For example, to perform angioplasty in thecarotid arteries, which have an inner diameter of about 4 to 6 mm, asuitably sized guide catheter must be used. This restricts the size ofthe catheter 100 that may be disposed within the guide catheter. Atypical diameter of the catheter 100 may then be about 7 French or lessor about 65 to 91 mils. In a second embodiment described below, acatheter for use in the coronary arteries is described. Of course, whichcatheter is used in which artery is a matter to be determined by thephysician, taking into account such factors as the size of theindividual patient's affected arteries, etc.

[0062] The outer tube 103 houses the catheter 100 while the lattertraverses the length of the guide catheter 102. The outer tube 103 mayhave a diameter of about 4 French to 7 French, and the same may be madeof polyether blockamide, poly-butylene terephtalate, polyurethane,polyamide, polyacetal polysulfone, polyethylene, ethylenetetrafluoroethylene, and other similar materials.

[0063] The distal end of the outer tube 103 adjoins the proximal end ofthe dual balloon 134. The outer tube 103 provides a convenient locationfor mounting a proximal end of an outer balloon 104 within the dualballoon 134, and further may provide an inlet 128 for providing a fluidsuch as a liquid to a first interior volume 106 between the dualballoons. In some cases, an inlet 128 per se may not be necessary: thefluid, which may also be a sub-atmospheric level of gas or air, may beprovided during manufacture in the first interior volume 106. In thiscase, the proximal and distal ends of the first interior volume may besealed during manufacture. The inlet 128 may be at least partiallydefined by the annular volume between the interior of the outer tube 103and the exterior of the inner tube 122.

[0064] The dual balloon 134 includes an outer balloon 104 and an innerballoon 108. Between the two is the first interior volume 106. The outerballoon 104 may be inflated by inflating the interior volume 106. Theinner balloon 108 has a second interior volume 110 associated with thesame. The inner balloon 108 may be inflated by inflating the secondinterior volume 110.

[0065] To avoid the occurrence of bubbles in the bloodstream, both theinner balloon 108 and the outer balloon 104 may be inflated usingbiocompatible liquids, such as Galden® fluid, perfluorocarbon-basedliquids, or various contrast agents. Fluids such as DMSO, d-limonene,and the like may also be employed. There is no need that the fluidinflating one of the interior volumes be the same fluid as thatinflating the other. Additional details on these fluids are describedbelow.

[0066] In the case of the first interior volume 106, this fluid may be,e.g., stationary or static: in other words, it need not be circulated.In the case of the second interior volume 110, this fluid would ingeneral be circulated by an external chiller (not shown). The chillermay be, e.g., a gear pump, peristaltic pump, etc. It may be preferableto use a gear pump over a peristaltic pump as the attainable pressure ofthe former is generally greater than that of the latter. Moreover, gearpumps have the advantageous property of being linear, i.e., their outputvaries in direction proportion with their revolutions per minute. Twotypes of gear pumps which may be employed include radial spur gear pumpsand helical tooth gear pumps. Of these, the helical tooth gear pump maybe more preferable as the same has been associated with higher pressuresand a more constant output. The ability to achieve high pressures may beimportant as the cooling fluid is required to pass through a fairlynarrow, e.g., five to seven French, catheter at a certain rate. For thesame reason, the viscosity of the fluid, at the low temperatures, shouldbe appropriately low. In this way, e.g., the flow may be increased. Forexample, an appropriate type of fluid may be Galden® fluid, and inparticular Galden® fluid item number “HT-55”, available from AusimontInc. of Thorofare, N.J. At −55° C., this fluid has a viscosity of 2.1centiStokes. At −70° C., this fluid has a viscosity of 3.8 centiStokes.It is believed that fluids with such viscosities at these temperatureswould be appropriate for use.

[0067] On occasion certain perfluorocarbon fluids, such as Galden fluidand d-limonene, may be known to outgas the dissolved nitrogen, oxygen,etc., if injected into the systemic circulation, despite their beingotherwise biocompatible. Such outgassing has deleterious consequences.

[0068] To avoid this outgassing, a procedure may be employed to void thefluids of dissolved gases. The procedure may also be employed onnon-outgassing fluids, without damaging the fluid, this feature allowinga single circulation to be employed for numerous types of fluids. Thismethod is shown in FIG. 18.

[0069] In a first step, a fluid to be treated is introduced into avessel in which a vacuum can be achieved (step 802). This, or any of theother steps, may either be done as a pre-treatment for fluid to be usedas a circulating fluid or can be done within a circulating fluid consoleto “on-the-fly” treatment. The fluid is then placed in a location wherethe same may be stirred, such as on a magnetic stir plate (step 804). Areasonably pure grade, USP or better, of helium is then diffused intoand through the fluid for a period of time, such as 20-30 minutes, whilethe fluid is stirred, e.g., with a Teflon-coated stir bar (step 806). Atthe end of this time period, the fluid diffusion may be stopped, and avacuum pulled on the fluid for a second period of time, e.g., 5 minutes,while the fluid is being optionally at least slightly stirred. The fluidmay then be ready for use.

[0070] As noted, the fluid degassing process may be done in line andcontinuously with the circulation process. An in-line sensor may beused, with an alarm, to ensure that the fluid is void of any dissolvedgases and is safe for use.

[0071] Returning to the structure of the balloons, the so-called “cones”of the balloons 108 and 104, indicated generally by reference numeral132, may be made somewhat thicker than the remainder of the balloonsections. In this way, the heat transfer efficiency in these sections issignificantly less than over the remainder of the balloon sections, this“remainder” effectively defining a “working region” of the balloon. Inthis way, the cooling or “cryoplasty” may be efficiently localized tothe affected area rather than spread over the length of the balloon.

[0072] The inner tube 122 is disposed within the interior of the dualballoon 134 and within the interior of the guide catheter 102. The innertube 122 includes a supply lumen 120, a return lumen 118, and aguidewire lumen 116. The guidewire lumen 116 may have sizes of, e.g., 17or 21 mils inner diameter, in order to accommodate current standardsized guidewires, such as those having an outer diameter of 14 mils.This structure may be preferable, as the pressure drop encountered maybe substantially less. In use, the supply lumen 120 may be used tosupply a circulating liquid to the second interior volume 110. Thereturn lumen 118 may be used to exhaust the circulating liquid from thesecond interior volume to the external chiller. As may be seen from FIG.1A, both lumens 118 and 120 may terminate prior to the distal end 114 ofthe catheter 100. The lumen arrangement may be seen more clearly in FIG.1B. FIG. 1C shows an alternate such arrangement, and one that mayprovide an even better design for minimal pressure drop. In this design,lumens 118′ and 120′ are asymmetric about guidewire lumen 116′.

[0073] A set of radio opaque marker bands 112 may be disposed on theinner tube 122 at locations substantially adjacent the cones 132 todefine a central portion of the “working region” of the balloons 104 and108. This working region is where the “cryoplasty” procedures describedbelow may substantially occur.

[0074] As noted above, the proximal portion of the outer balloon 104 ismounted on the outer tube 103 at its distal end. The distal end of theouter balloon 104 is secured to the distal end of the catheter 100 andalong the inner tube 122. In contrast, both the proximal and distal endsof the inner balloon 108 may be secured to the inner tube 122 to createa sealed second interior volume 110.

[0075] At least two skives 124 and 126 may be defined by the inner tube122 and employed to allow the working fluid to exit into the secondinterior volume 110 and to exhaust the same from the second interiorvolume 10. As shown in the figure, the skive 124 is in fluidcommunication with the lumen 120 and the skive 126 is in fluidcommunication with the lumen 118. Here, “fluid communication” refers toa relationship between two vessels where a fluid pressure may cause anet amount of fluid to flow from one vessel to the other.

[0076] The skives may be formed by known techniques. A suitable size forthe skives may be from about 50 mils to 125 mils.

[0077] A plurality of optional tabs 119 may be employed to roughly orsubstantially center the inner tube 122 within the catheter 100. Thesetabs may have the shape shown, the shape of rectangular or triangularsolids, or other such shapes so long as the flow of working fluid is notunduly impeded. In this specification, the phrase “the flow of workingfluid is not unduly impeded” is essentially equated to the phrase“substantially center”. The tabs 119 may be made of polyetherblockamide, poly-butylene terephtalate, polyurethane, polyamide,polyacetal polysulfone, polyethylene, ethylene tetrafluoroethylene, andother similar materials, and may have general dimensions of from about 3mils to 10 mils in height, and by about 10 mils to 20 mils in width.

[0078] In a method of use, the guide catheter 102 may be inserted intoan affected artery or vein such that the distal tip of the guidecatheter is just proximal to an affected area such as a calcified areaor lesion. Of course, it is noted that typical lesions do not occur inthe venous system, but only in the arterial.

[0079] This step provides a coarse estimate of proper positioning, andmay include the use of fluoroscopy. The guide catheter may be placedusing a guide wire (not shown). Both the guide catheter and guide wiremay already be in place as it may be presumed a balloon angioplasty orstent placement has previously been performed.

[0080] The catheter 100 may then be inserted over the guide wire via thelumen 116 and through the guide catheter 102. In general, both a guidewire and a guide catheter are not strictly necessary—one or the othermay often suffice. During insertion, the dual balloon 134 may beuninflated to maintain a minimum profile. In fact, a slight vacuum maybe drawn to further decrease the size of the dual balloon 134 so long asthe structural integrity of the dual balloon 134 is not therebycompromised.

[0081] When the catheter 100 is distal of the distal tip of the guidecatheter 102, a fine positioning step may occur by way of the radioopaque marker bands 112. Using fluoroscopy, the location of the radioopaque marker bands 112 can be identified in relation to the location ofthe lesion. In particular, the catheter may be advantageously placed atthe location of the lesion and further such that the lesion is betweenthe two marker bands. In this way, the working region of the balloon 134will substantially overlap the affected area, i.e., the area of thelesion.

[0082] Once placed, a biocompatible heat transfer fluid, which may alsocontain contrast media, may be infused into the first interior volume106 through the inlet 128. While the use of contrast media is notrequired, its use may allow early detection of a break in the balloon104 because the contrast media may be seen via fluoroscopy to flowthroughout the patient's vasculature. Subsequently a biocompatiblecooling fluid may be circulated through the supply lumen 120 and thereturn lumen 118. Before or during the procedure, the temperature of thebiocompatible cooling fluid may be lowered to a therapeutic temperature,e.g., between −40° C. and −60° C., although the exact temperaturerequired depends on the nature of the affected area. The fluid exits thesupply lumen 120 through the skive 124 and returns to the chillerthrough the skive 126 and via the return lumen 118. It is understoodthat the respective skive functions may also be reversed withoutdeparting from the scope of the invention.

[0083] The biocompatible cooling fluid in the second interior volume 110chills the biocompatible heat transfer fluid within the first interiorvolume 106 to a therapeutic temperature of, e.g., between about −25° C.and −50° C. The chilled heat transfer fluid transfers thermal energythrough the wall of the balloon 104 and into the adjacent intimalvascular tissue for an appropriate therapeutic length of time. This timemay be, e.g., about ½ to 4 minutes.

[0084] Upon completion of the therapy, the circulation of thebiocompatible cooling fluid may cease. The heat transfer fluid withinthe first interior volume 106 may be withdrawn though the inlet 128. Theballoons 104 and 108 may be collapsed by pulling a soft vacuum throughany or all of the lumens 124, 126, and 128. Following collapse, thecatheter 100 may be withdrawn from the treatment site and from thepatient through the guide catheter 102.

[0085] To inhibit restenosis, the following therapeutic guidelines maybe suggested: Minimum Average Maximum Temperature −20° C. −55° C. −110°C. of heat transfer fluid Temperature 0° C. to −10° C. −20° C. to −50°C. to achieved at −30° C. −100° C. intimal wall Depth of 10ths of mm 1mm 3 mm penetration of intema/media Length of 30 seconds 1-2 min 4-5 mintime fluid is circulating

[0086] Substantially the same catheter may be used to treat atrialfibrillation. In this method, the catheter is inflated as above once itis in location. The location chosen for treatment of atrial fibrillationis such that the working region spans a portion of the left atrium and aportion of the affected pulmonary vein. Thus, in this embodiment, theworking region of the catheter may have a length of about 5 mm to 30 mm.The affected pulmonary vein, of the four possible pulmonary veins, whichenter the left atrium, may be determined by electrophysiology studies.

[0087] To maneuver the catheter into this location, a catheter with aneedle point may first be inserted at the femoral vein and routed up tothe right atrium. The needle of the catheter may then be poked throughthe interatrial septum and into the left atrium. The catheter may thenbe removed if desired and a guide catheter disposed in the samelocation. A guide wire may be used through the guide catheter and may bemaneuvered at least partially into the pulmonary vein. Finally, acatheter such as the catheter 100 may be placed in the volume definingthe intersection of the pulmonary vein and the left atrium.

[0088] A method of use similar to that disclosed above is then employedto cool at least a portion of, and preferably all of, thecircumferential tissue. The coldness of the balloon assists in theadherence of the circumferential tissue to the balloon, this featureserving to increase the overall heat transfer rate.

[0089] The catheter 100 above may be particularly useful for proceduresin the carotid arteries by virtue of its size. For use in the coronaryarteries, which are typically much smaller than the carotid artery, aneven smaller catheter may be desired. For example, one with an outerdiameter less than 5 French may be desired.

[0090] Referring to FIG. 2A, a catheter 200 is shown according to asecond embodiment of the invention. This embodiment may be particularlyuseful for use in the coronary arteries because the dimensions of thecatheter 200 may be considerably smaller than the dimensions of thecatheter 100. However, in several ways the catheter 200 is similar tothe above-described catheter 100. In particular, the catheter 200 has aproximal end 230 and a distal end 214 and may be used within a guidecatheter 202. The catheter 200 includes an outer tube 203, a dualballoon 234, and an inner tube 222.

[0091] The ability to place the guide catheter is a significant factorin the size of the device. For example, to perform angioplasty in thecoronary arteries, which have an inner diameter of about 1½ to 4½ mm, asuitably sized guide catheter may be used. This then restricts the sizeof the catheter 200 which may be disposed within the guide catheter. Atypical diameter of the catheter 200 may then be about 3 French or lessor about 35-39 mils. The same may be placed in the femoral artery inorder to be able to track to the coronary arteries in a known manner.

[0092] Analogous to these features in the catheter 100, the outer tube203 houses the catheter 200 and may have an outside diameter of about 5French to 7 French, and the same may be made of similar materials. Thedistal end of the outer tube 203 adjoins the proximal end of the dualballoon 234. The outer tube 203 provides a mounting location for anouter balloon 204, and further provides an inlet 228 for providing afluid such as a liquid to a first interior volume 206 between the dualballoons. As noted in connection with catheter 100, an inlet 228 per semay not be necessary: the fluid, which may also be a sub-atmosphericlevel of air, may be provided in the first interior volume 206. Also asabove, the proximal and distal ends of the volume may be sealed duringmanufacture. The inlet 228 may be at least partially defined by theannular volume between the interior of the outer tube 203 and theexterior of the inner tube 222.

[0093] The dual balloon 234 includes an outer balloon 204 and an innerballoon 208. These balloons are basically similar to balloons 104 and108 described above, but may be made even smaller for use in the smallercoronary arteries.

[0094] The same types of fluids may be used as in the catheter 100.

[0095] The inner tube 222 is disposed within the interior of the dualballoon 234 and within the interior of the guide catheter 202. The innertube 222 includes a supply lumen 220 and a return lumen 218.

[0096] A set of radio opaque marker bands 212 may be disposed on theinner tube 222 for the same reasons disclosed above in connection withthe marker bands 112.

[0097] As noted above, the proximal portion of the outer balloon 204 ismounted on the outer tube 203 at its distal end. The distal end of theouter balloon 204 is secured to the distal end of the catheter 200 andalong the inner tube 222. In contrast, both the proximal and distal endsof the inner balloon 208 may be secured to the inner tube 222 to createa sealed second interior volume 210.

[0098] At least two skives 224 and 226 may be defined by the inner tube222 and employed to allow the working fluid to exit into the secondinterior volume 210 and to exhaust the same from the second interiorvolume 210.

[0099] A plurality of optional tabs 219 may be employed to roughly orsubstantially center the inner tube 222 within the catheter 200 as incatheter 100. These tabs may have the same general geometry and designas tabs 119. Of course, they may also be appropriately smaller toaccommodate the smaller dimensions of this coronary artery design.

[0100] The tabs 119 and 219 are particularly important in the catheters100 and 200, as contact by the inner tube of the outer tube may also beassociated with an undesired conductive heat transfer prior to theworking fluid reaching the working region, thereby deleteriouslyincreasing the temperature of the working fluid at the working region.

[0101] The method of use of the catheter 200 is generally the same asfor the catheter 100. Known techniques may be employed to place thecatheter 200 into an affected coronary artery. For the catheter 200, anexternal guidewire may be used with appropriate attachments to thecatheter.

[0102] Referring to FIG. 3, an alternative embodiment of a catheter 300which may be employed in PV ablation is detailed. In this figure, a dualballoon system 301 is shown; however, the balloons are not one withinthe other as in FIG. 1. In this embodiment, a warm balloon 302 is distalof a cold balloon 304. Warm balloon 302 may be used, to anchor thesystem 301 against movements, which may be particularly useful within abeating heart. Cold balloon 304 may then be employed to cryo-ablate acircumferential lesion at the point where a pulmonary vein 306 entersthe left atrium 308.

[0103] Within the cold balloon 304, a working fluid may be introducedvia an outlet port 308 and may be retrieved via an inlet port 310. Ports308 and 310 may be skived in known fashion into the catheter shaftlumens whose design is exemplified below.

[0104] As noted above, the warm balloon 302 serves to anchor the system301 in the pulmonary vein and left atrium. The warm balloon 302 alsoserves to stop blood, which is traveling in the direction indicated byarrow 312, from freezing upon contact with the cold balloon 304. In thisway, the warm balloon 302 acts as an insulator to cold balloon 304.

[0105] As the warm balloon 302 does not require convective heat transfervia a circulating working fluid, it may be served by only one skivedport, or by two ports, such as an inlet port 314 and an outlet port 316,as shown in FIG. 3. In some embodiments, a separate lumen or lumens maybe used to fill the warm balloon. In an alternative embodiment, a valvemechanism may be used to fill the warm balloon using fluid from the coldballoon. In the case where only one port is used to fill the warmballoon, draining the same requires a slight vacuum or negative pressureto be placed on the lumen servicing the inlet/outlet port. A benefit tothe two lumen design is that the warm balloon may be inflated anddeflated in a more expeditious manner.

[0106] Typical pressures within the warm balloon may be about 1-2 atm(10-30 psi), and thus maintains a fairly low pressure. An appropriatefluid will be biocompatible, and may be Galden fluid, D5W, and so on.Typical pressures within the cold balloon may be about 5-7 atm, forexample about 6 atm (e.g., at about 100 psi), and thus maintains ahigher pressure. An appropriate fluid may be Galden fluid, e.g., HT-55,D5W, and so on. The volume of fluid required to fill the cold balloonmay vary, but may be about 4-8 cc. The cold balloon may be about 2 to 2½cm long, and have a diameter of 1 to 2½ cm.

[0107] In some embodiments, the warm balloon may be glued or otherwiseattached to the cold balloon. In the case where only one port is used tofill the warm balloon, draining both balloons may simply entail closingeither the return lumen or the supply lumen, and drawing a vacuum on theother. In this way, both the cold and warm balloons may be evacuated. Inany case, a standard medical “indeflator” may be used to pressurize andde-pressurize the various lumens and balloons.

[0108]FIG. 4 shows an embodiment of the arrangement of lumens within thecatheter. In particular, supply and return lumens for the cold balloon304 are shown by lumens 318 and 320, respectively. Supply and returnlumens for the warm balloon 302 are shown by lumens 322 and 324,respectively, although as noted only one may be used as required by thedictates of the user. A guidewire lumen 326 is also shown. Analternative arrangement is shown in FIG. 5, where the correspondinglumens are shown by primes.

[0109] In the above lumen designs, the exterior blood is exposed to thecold supply flow. Referring to FIG. 6, an alternative lumen design isshown in which the cold fluid supply lumen 328 is exposed to only thecold fluid return lumen 330. An insulation space 332 may also beemployed. In this way, the heat flux from the exterior flow is minimizedand the cold fluid may reach the cold balloon at a lower temperature.One drawback to such a system is that the operational pressure may behigher.

[0110] Referring back to FIG. 4, the overall catheter outer diameter maybe about 0.130″, e.g. about 10 French, including an insulation sleeveand guide discussed below. The catheter shaft 303 itself may be about0.110″ and may be made of, e.g., polyethylene (PE), and preferably acombination of a low density PE and a high density PE.

[0111] The inlet and outlet ports or inlet/outlet port of the warmballoon may be skived from the lumens 322 and 324. Referring to FIG. 7,the warm balloon 302 itself may be made of a sleeve 332 of siliconetubing of, e.g., 35 durometer on the “D” scale, and held in place by twopieces of PET heat shrink tubing 334. Alternative methods of securingthe warm balloon during inflation may include metal bands or anadhesive.

[0112] Referring back to FIG. 3, marker bands 336 may be employed withineither or both of the cold balloon and warm balloon to assist thephysician is disposing the same in an appropriate location. The markerbands typically denote the working areas of the balloons, and may bemade of Pt, Iridium, Au, etc.

[0113] In the ablation procedure, the working cold fluid may exit thecirculation system or chiller at, e.g., about −85° C. The circulationsystem or chiller may be, e.g., a two-stage heat exchanger. The fluidmay then enter the catheter at about −70° C. to about −75° C., and maystrike the balloon at about −55° C. to about −65° C. The overallprocedure may take less than a minute to circumferentially ablate thedesired tissue up to several minutes. Of course, these numbers are onlyexemplary and the same depend on the design of the system and fluidsused.

[0114] Mapping electrodes 338 may be employed at the distal end of thewarm balloon. These mapping electrodes may each have a wire attached,the wires extending down, e.g., the supply and return lumens for thewarm fluid or the cold fluid. The mapping electrodes 338 may be used todetect stray electrical fields to determine where ablation may be neededand/or whether the ablation procedure was successful. The mappingelectrodes may typically be about 2-3 mm apart from each other.

[0115] Construction of the warm balloon typically involves adhering thesame to the shaft 303 and skiving the inlet and outlet ports. In someinstances, it may be desired to place a silicone sleeve 340 on theproximal and/or distal ends of the warm and/or cold balloons. Thesilicone sleeve 340 may then serve to further insulate the non-workingsections of the balloons from blood that would otherwise potentiallyfreeze during a procedure. The silicone sleeve would typically beattached only at a portion of its length, such as that indicated bycircle 342, so that the same may slide along the balloon as the balloonis inflated. In addition to insulation effects, the silicone sleeve alsoserves to assist in collapsing the balloon during deflation.

[0116] The entire catheter shaft 303 may be surrounded by an insulationcatheter sleeve 344 (see FIG. 4). Sleeve 344 may have a thickness of,e.g., 0.01 inches, and may be made of a foamed extrusion, e.g., thatwith voids of air disposed within. The voids further assist theinsulating effect since their heat transfer is extremely low. A void topolymer ratio of, e.g., 20% to 30% may be particularly appropriate. Suchfoamed extrusions are available from, e.g., Applied Medical Resources inLaguna Niguel, Calif., or Extrusioneering, Inc., in Temecula, Calif.

[0117] To prevent damage to tissue other than where the ablation is tooccur, such as at the insertion site near the femoral vein and aroundthe puncture point through the atrial septum, an insulation sleeve maybe used as noted above.

[0118] Of course, in certain situations, the warm balloon may beomitted, and only the therapeutic cold balloon used. In a particularlysimple system, the therapeutic cold balloon may be employed as a singleballoon system without the use of tabs. Such a system may beparticularly convenient to manufacture and install.

[0119] In another embodiment, the invention may employ a porous ormicroporous balloon to enhance heat transfer between the working fluidand the tissue to be treated. Referring to FIG. 8, a catheter 400 isshown according to a first embodiment of the invention. The catheter 400has a proximal end 430 and a distal end 414. The catheter 400 may beused within a guide catheter 402, and generally includes an outer tube403, a dual balloon 434, and an inner tube 422. These parts will bediscussed in turn.

[0120] The guide catheter 402 may be similar to that discussed above inconnection with FIG. 1.

[0121] The outer tube 403 houses the catheter 400 while the lattertraverses the length of the guide catheter 402. The outer tube 403 mayhave a diameter of about 4 French to 7 French, and the same may be madeof polyether blockamide, poly-butylene terephtalate, polyurethane,polyamide, polyacetal polysulfone, polyethylene, ethylenetetrafluoroethylene, and other similar materials.

[0122] The distal end of the outer tube 403 adjoins the proximal end ofthe dual balloon 434. The outer tube 403 provides a convenient locationfor mounting a proximal end of an outer balloon 404 within the dualballoon 434, and further may provide an inlet 428 for providing a fluidsuch as a liquid to a first interior volume 406 between the dualballoons. In some cases, an inlet 428 per se may not be necessary: thefluid, which may also be a sub-atmospheric level of gas or air, may beprovided during manufacture in the first interior volume 406. In thiscase, the proximal and distal ends of the first interior volume may besealed during manufacture. The pressure of inflation would then providethe force necessary to cause the fluid within the first interior volumeto at least partially “leak” to the tissue. The inlet 428 may be atleast partially defined by the annular volume between the interior ofthe outer tube 403 and the exterior of the inner tube 422.

[0123] The dual balloon 434 includes an outer balloon 404 and an innerballoon 408. Between the two is the first interior volume 406. The outerballoon 404 may be inflated by inflating the interior volume 406. Theinner balloon 408 has a second interior volume 410 associated with thesame. The inner balloon 408 may be inflated by inflating the secondinterior volume 410.

[0124] To avoid the occurrence of bubbles in the bloodstream, both theinner balloon 408 and the outer balloon 404 may be inflated usingbiocompatible liquids, such as Galden® fluid, perfluorocarbon-basedliquids, or various contrast agents. There is no need that the fluidinflating one of the interior volumes be the same fluid as thatinflating the other. Additional details on these fluids were describedabove.

[0125] In the case of the first interior volume 406, this fluid may be,e.g., stationary or static: in other words, it need not be circulated.In the case of the second interior volume 410, this fluid would ingeneral be circulated by an external chiller (not shown). The chillermay be, e.g., a gear pump, peristaltic pump, etc. It may be preferableto use a gear pump over a peristaltic pump for the reasons describedabove.

[0126] The inner tube 422 is disposed within the interior of the dualballoon 434 and within the interior of the guide catheter 402. The innertube 422 includes a supply lumen 420, a return lumen 418, and aguidewire lumen 416. The guidewire lumen 416 may have sizes of, e.g., 17or 21 mils inner diameter, in order to accommodate current standardsized guidewires, such as those having an outer diameter of 14 mils.This structure may be preferable as described above. The return lumen418 may be used to exhaust the circulating liquid from the secondinterior volume to the external chiller. As may be seen from FIG. 8,both lumens 418 and 420 may terminate prior to the distal end 414 of thecatheter 400. The lumen arrangement may be similar to that of FIG. 1B or1C.

[0127] A set of radio opaque marker bands 412 may be disposed on theinner tube 422 at locations substantially adjacent the cones 432 todefine a central portion of the “working region” of the balloons 404 and408.

[0128] As noted above, the proximal portion of the outer balloon 404 ismounted on the outer tube 403 at its distal end. The distal end of theouter balloon 404 is secured to the distal end of the catheter 400 andalong the inner tube 422. In contrast, both the proximal and distal endsof the inner balloon 408 may be secured to the inner tube 422 to createa sealed second interior volume 410.

[0129] At least two skives 424 and 426 may be defined by the inner tube422 and employed to allow the working fluid to exit into the secondinterior volume 410 and to exhaust the same from the second interiorvolume. As shown in the figure, the skive 424 is in fluid communicationwith the lumen 420 and the skive 426 is in fluid communication with thelumen 418. Here, “fluid communication” refers to a relationship betweentwo vessels where a fluid pressure may cause a net amount of fluid toflow from one vessel to the other.

[0130] The skives may be formed by known techniques. A suitable size forthe skives may be from about 50 mils to 125 mils.

[0131] At least one pore 415 may be provided within the outer balloon404. In this way, a portion of the fluid within the first interiorvolume 406 may leak to the exterior of the outer balloon 404, contactingthe tissue and providing enhanced heat transfer, due to conduction,between the fluid and the tissue to be treated.

[0132] The method of making a porous or microporous balloon is known,and either may be employed in this application. Such balloons arealternatively known as “weeping” balloons. In such balloons, pore sizescan be controlled at least to the micron range. The pore size determinesthe rate of release of the fluid. A conflicting requirement is that theballoon must be inflated and deployed, this requirement having theeffect that the balloon must be strong and at least about 1-2atmospheres of pressure must be maintained in the balloon.

[0133] These requirements can still be met in the present porous ormicroporous balloon as the fluid leakage is generally small, especiallyas the time of therapy may be on the order of 1-2 consecutive treatmentsat 60-90 seconds each. Over such a period of time, it may be expectedthat only 1-2 ml may be leaked.

[0134] In alternative embodiments, the pores can be designed to beplaced in a band, so as to only leak at about where the circumferentialregion of tissue is located. Alternatively, the pores can be placed in ahelix, spiral, e.g., relative to an axis 401 of the catheter, or othersuch shape as dictated by the demands of the user. Only one pore may beused in applications where only a minimum of enhanced conductivity isrequired.

[0135] In a treatment-of-restenosis method of use, the guide catheter402 may be inserted into an affected artery or vein such that the distaltip of the guide catheter is just proximal to an affected area such as acalcified area or lesion.

[0136] The catheter 400 may then be inserted over the guide wire via thelumen 416 and through the guide catheter 402. In general, both a guidewire and a guide catheter are not strictly necessary—one or the othermay often suffice. During insertion, the dual balloon 434 may beuninflated to maintain a minimum profile. In fact, a slight vacuum maybe drawn to further decrease the size of the dual balloon 434 so long asthe structural integrity of the dual balloon 434 is not therebycompromised.

[0137] The fine positioning step by way of the radio opaque marker bands412 and as described above in connection with FIG. 1 may then occur.Once placed, a biocompatible heat transfer fluid, which may also containcontrast media, may be infused into the first interior volume 406through the inlet 428. This fluid then begins to leak via pores 415,flowing between the balloon and the tissue to be treated and enhancingthe conductive heat transfer between the two.

[0138] The biocompatible cooling fluid may then be circulated throughthe supply lumen 420 and the return lumen 418. As noted above inconnection with FIG. 1, the fluid exits the supply lumen 420 through theskive 424 and returns to the chiller through the skive 426 and via thereturn lumen 418. It is understood again that the respective skivefunctions may also be reversed without departing from the scope andspirit of the invention.

[0139] Upon completion of the therapy, the circulation of thebiocompatible cooling fluid may cease. The remaining heat transfer fluidwithin the first interior volume 406 may be withdrawn though the inlet428. The balloons 404 and 408 may be collapsed by pulling a soft vacuumthrough any or all of the lumens 424, 426, and 428. Following collapse,the catheter 400 may be withdrawn from the treatment site and from thepatient through the guide catheter 402.

[0140] Referring to FIG. 9, an alternative embodiment of a catheterwhich may be employed in PV ablation is detailed. In this figure, a dualballoon system 501 is shown which is similar to the embodiment of FIG.3.

[0141] However, the balloons are not one within the other as in FIG. 1.In this embodiment, warm balloon 502 may be used to anchor the system501 against movements, while cold balloon 504 may be employed tocryo-ablate a circumferential lesion at the point where a pulmonary vein506 enters the left atrium 508.

[0142] Within the cold balloon 504, a working fluid may be introducedvia an outlet port 508 and may be retrieved via an inlet port 510. Ports508 and 510 may be skived in known fashion into the catheter shaftlumens whose design is exemplified below. The cold balloon 504 may be aporous or microporous balloon, having pores as indicated in FIG. 9 bypores 515.

[0143] As in the embodiment of FIG. 3 noted above, the warm balloon 502serves to anchor the system 501 in the pulmonary vein and left atrium.The warm balloon 502 also serves to stop blood, which is traveling inthe direction indicated by arrow 512, from freezing upon contact withthe cold balloon 504. In this way, the warm balloon 502 acts as aninsulator to cold balloon 504.

[0144] As the warm balloon 502 does not require convective heat transfervia a circulating working fluid, it may be served by only one skivedport, or by two ports, such as an inlet port 514 and an outlet port 516,as shown in FIG. 9. In some embodiments, a separate lumen or lumens maybe used to fill the warm balloon. In an alternative embodiment, a valvemechanism may be used to fill the warm balloon using fluid from the coldballoon. In the case where only one port is used to fill the warmballoon, draining the same requires a slight vacuum or negative pressureto be placed on the lumen servicing the inlet/outlet port.

[0145] Typical pressures within the warm balloon may be as above.Typical pressures within the porous cold balloon may be about 1-2 atm,for example about 1.5 atm. An appropriate cryogenic fluid may be Galdenfluid, e.g., HT-55, or others with similar properties. The volume offluid required to fill the cold balloon may vary, but may be about 4-8cc. The cold balloon may be about 2 to 2½ cm long, and have a diameterof 1 to 4 cm.

[0146] A porous or microporous balloon may also be employed in anapplication in which the above or similar balloons are employed to treatrestenosis. For example, following an angioplasty procedure, theangioplasty balloon may be removed while the guidewire left in place. Aswith treatment-of-atrial fibrillation procedures, the balloon may bedelivered up to the location of treatment via the guidewire, andoperated for a minute, or other appropriate time as determined by, e.g.,the physician. In the restenosis application, the outer diameter of thecatheter would typically be less than about 6 French, as the same wouldrequire compatibility with existing coronary angioplasty hardware, suchas a 9 French guide catheter.

[0147] In another embodiment, referring to FIGS. 15 and 16, a device 701is shown which may be employed for treatment of atrial fibrillation bycircumferential ablation, while allowing blood flow to continue, therebyreducing, minimizing, or eliminating the risk of stroke during longcryoablation procedures. Referring to the figures, an annular ringballoon 706 having a toroidal shape is fluidically coupled to a cathetershaft 708 near the distal end 714 thereof. The annular ring balloon 706may be inflated by any of the various fluids described elsewhere in thisspecification, and may further cause the cryoablation of acircumferential region of tissue at a location where the pulmonary vein704 meets the left atrium 718, i.e., the ostium of the pulmonary vein.Blood flow is then only minimally impeded as the same flows betweenlocation A and location B. The diameter of the interior annulus may beappropriately sized to accomplish this objective.

[0148] A more detailed view is shown in FIG. 16. In this figure, asupply lumen 712, also termed a catheter supply lumen, provides thecryoablation fluid to an interior of the annular ring balloon 706 toinflate the same. A roughly annular portion 702 of the shaft 708surrounding the supply lumen 712 serves as a catheter return lumen forreturn of the cryoablation fluid to exhaust the balloon.

[0149] A portion of the annular ring balloon 706 adjacent the supplylumen is denoted fluid inlet 720, while a portion of the annular ringballoon 706 adjacent the return lumen is denoted fluid outlet 722. Fluidinlet 720 may be offset, in the direction of the axis of shaft 708, fromfluid outlet 722. For example, the fluid inlet 720 may be slightlyproximal of the fluid outlet 722. This accomplishes a greater ease intrackability of the uninflated device, as well as more convenientmanufacturability.

[0150] The radius of expansion should be sufficient to enable overlap710 at the point where the balloon is coupled to the shaft, so as toensure a contiguous cryo-ablation injury, but not so great as to impedethe blood flow. A view even better showing this is shown in FIG. 17.

[0151] The above device of FIGS. 15-17 may further be employed forangioplasty procedures, as will be realized given the teaching above.

[0152] The annular ring balloon may be manufactured in a way similar tocurrent balloons. It may be a basic cylinder with tapered ends that matewith the catheter shaft. The plane of the balloon is normal to thecatheter shaft. This concept is different from centering balloons in anumber of ways, which typically are designed to enable blood flowbetween the vascular wall and the balloon. It may also be distinct fromcoronary perfusion catheters that are designed to re-route blood flowthrough the catheter shaft. The outer diameter of the toroidal annularring balloon may be about 1 cm.

[0153] While the description with respect to FIGS. 15-17 has beendescribed such that the supply lumen only extends to a fluid inlet ofthe annular ring balloon, in another embodiment, the supply lumenextends throughout the annular ring balloon. This is then termed aballoon supply lumen and the same is indicated in FIG. 16 by dottedlines showing balloon supply lumen 721 and balloon return lumen 723. Inthis way, the annular ring balloon itself is biaxial, having a balloonsupply and balloon return lumen within. In this case, the balloon returnlumen, which is generally warmer, may be disposed towards the innerradius of the balloon, adjacent to which the blood is flowing.Correspondingly, the balloon supply lumen may be disposed towards theouter radius of the balloon, where the cryoablation is to occur.

[0154] Whether the application is for restenosis or for treatment ofatrial fibrillation, it is noted that on occasion tissue may bethermally damaged unintentionally. For example, at the point wherecatheter tubing enters the patient, relatively constant contact of thetubing with the tissue may lead to thermal damage. The same may be trueat the point where tubing penetrates the atrial septum, in atrialfibrillation situations. To treat such situations, one or a combinationof the below embodiments may be employed. In these embodiments,insulating or warming the affected regions is performed via modifying aportion or more of the full-length introducer or sheath that houses thecatheter from the site of insertion into the left atrium.

[0155] Referring to FIG. 10, an embodiment of an introducer sheath 600is shown that prevents freezing around the site of the percutaneousinsertion. Introducer or introducer sheath 600 generally has anintroducer tube 606 at a distal end and a hub 604 at a proximal end. Acatheter 608 for cryoablation may be seen in schematic form emergingfrom the distal end of the introducer tube 606. Warmed fluid, such asinjection grade saline, is introduced via an optional insertion tube 602to the hub 604. This fluid traverses the annular region 610 between anexterior wall of the catheter shaft 608 and an interior wall of theintroducer tube 606. The fluid loses heat to the catheter, becomingcooled in the process, and exits the interior of the introducer ofsheath 600 via outlet ports 612. These outlet ports are positioned onthe introducer is such a way as to exhaust the cooled fluid directlyinto venous blood. Forced convection of the fluid between the cathetershaft and the introducer prevents the temperature on the exterior of theintroducer from falling to dangerous levels, such as near freezing.

[0156] In a second embodiment, a resistive heater may be employed. Inparticular, referring to FIG. 11, an embodiment of an introducer orsheath 600′ is shown that prevents freezing around the site of thepercutaneous insertion. Introducer or sheath 600′ generally has anintroducer tube 606′ at a distal end and a hub 604′ at a proximal end. Acatheter 608 for cryoablation may be seen in schematic form emergingfrom the distal end of the introducer tube 606′. A resistive heater 614is wound around the introducer tube 606′ and is conductively coupled towires 616 leading to control unit 618. The heater 614 may be in the formof a helical wire or strip, applied to the exterior of the introducertube 606′, and of sufficient length so as to extend into the accessedvein. The heater may be characterized in such a way that the resistanceis a function of temperature.

[0157] An external power source and control unit 618 may be employed tomaintain the temperature of the heating coil 614 at the desired value,preferably nominal body temperature (37° C.), thus preventing thermaldamage to adjacent tissue. Of course, the external power source andcontrol unit may be within one or two or more separate physical units.

[0158] The helical form of coil 614 may be preferred; however, variousother geometries of resistive heaters may also be used.

[0159] In a related embodiment, referring to FIG. 12, another embodiment600″ is shown that prevents freezing of tissue around the site ofpercutaneous insertion. A resistive heater 622 in the form of a helicalwire or strip is applied to the exterior of a sleeve 620 which fitstightly over and yet is free to move on the exterior surface of theintroducer 606″. When the catheter and introducer are in place, thesleeve 620 is positioned so as to encompass the tissue between theinsertion site and the interior of the accessed vein. An external powersource and control circuit, which may be similar to that employed inFIG. 11, are employed to maintain the temperature of the heating coil622 at the desired value, preferably nominal body temperature (37° C.),thus preventing thermal damage to adjacent tissue. As before, thehelical form, while preferred, is not the only geometry of resistiveheater to which this disclosure may apply.

[0160] The location of percutaneous insertion is not the only locationat which tissue damage may occur. For example, damage may also occur atthe atrial septum or other locations where the device may rest againsttissue for periods of time.

[0161] Referring to FIG. 13, an embodiment is shown that preventsfreezing of tissue around the site of penetration of the introducerthrough the atrial septum. A resistive heater 626 in the form of ahelical wire or strip is applied to the exterior of the introducer 632near the distal tip 624, so that the length of the heater 626encompasses the entire path of the introducer 632 through the atrialseptum 628. As noted above, an external power source and control circuitare employed to maintain the temperature of the heating coil at thedesired value, preferably nominal body temperature (37° C.), thuspreventing thermal damage to adjacent tissue. The helical form, whilepreferred, is not the only geometry of resistive heater to which thisdisclosure may apply.

[0162] Referring to FIG. 14, another embodiment is shown that preventsfreezing of tissue around the site of penetration of the introducerthrough the atrial septum. Several holes 634 are drilled around thecircumference of the introducer 636 proximal to the distal tip 638.These holes 634 are placed so that on proper placement of the introducer636, a fluid path is created between the right and left atria. Thisfluid path is along an annular sleeve formed by the interior wall of theintroducer and the exterior wall of the catheter. The oscillatingpressure gradient between the two atria induces a corresponding flow ofblood along the annular path connecting the distal tip of the introducerto the holes on the introducer within the contralateral atrium. Forcedconvection of blood between the catheter shaft and introducer preventsthe temperature on the exterior of the introducer from falling todangerous levels (near freezing).

[0163] In this embodiment, as well as in others, the sheath orintroducer serves a number of functions in addition to its role as aguide. For example, it provides another important layer of insulation sothat heat from the body does not unduly enter the catheter,unnecessarily heating the working fluid inside prior to the fluidreaching the cryoablation balloon.

[0164] The invention has been described above with respect to particularembodiments. It will be clear to one of skill in the art that numerousvariations may be made from the above embodiments with departing fromthe spirit and scope of the invention. For example, the invention may becombined with stent therapies or other such procedures. The dual balloondisclosed may be used after angioplasty or may be an angioplasty balloonitself. Furthermore, while the invention has occasionally been termedherein a “cryoplasty catheter”, such a term is for identificationpurposes only and should not be viewed as limiting of the invention.Fluids that may be used as heat transfer fluids includeperfluorocarbon-based liquids, i.e., halogenated hydrocarbons with anether bond, such as FC 72. Other materials that may be used includeCFCs, Freon®, or chemicals that when placed together cause anendothermic reaction. Preferably, low viscosity materials are used asthese result generally in a lessened pressure drop. The balloons may bemade, e.g., of Pebax, PET/PEN, PE, PA 11/12, PU, or other suchmaterials. Either or both of the dual balloons may be doped to improvetheir thermal conductivities. The shafts of various tubes mentioned,such as inner tube 122, may be made of Pebax, PBT, PI/PEI, PU, PA 11/12,SI, or other such materials. The precise shapes and dimensions of theinner and outer lumens, while indicated in, e.g., FIGS. 1B, 1C, and 2B,may vary. The lumen design shown in FIGS. 1B-1C may be employed in thecatheter of FIG. 2A and vice-versa. Either a single cold balloon system,or a dual balloon system, may be employed in either or both of thementioned applications of treating restenosis or atrial fibrillation, orother such maladies. Embodiments of the invention may be employed in thefield of cold mapping, where a circle of tissue is cooled to see if theaffected part has been reached. If the affected tissue is that which isbeing cooled, a more vigorous cooling may be instituted. Othervariations will be clear to one of skill in the art, thus the inventionis limited only by the claims appended hereto.

What is claimed is:
 1. A device to treat tissue while preventing tissuedamage to adjacent tissue, comprising: an ablation catheter; anintroducer sheath for the ablation catheter, the introducer sheath atleast partially contacting tissue to be protected; a heater disposedadjacent or within the introducer sheath, the heater thermally coupledto the tissue; and a control unit for the heater.
 2. The device of claim1, wherein the heater is a resistive heater.
 3. The device of claim 1,wherein the heater includes an inlet tube fluidically coupled to aninterior of the introducer, and at least one outlet orifice disposed inthe introducer.
 4. The device of claim 1, wherein the heater includes aninlet sleeve with an input for a body fluid at a distal end of theintroducer sheath, wherein the inlet sleeve is fluidically coupled to aninterior of the introducer, and at least one outlet orifice disposed inthe introducer.
 5. The device of claim 4, wherein the inlet sleeve hasan annular shape along a portion thereof.
 6. The device of claim 2,wherein the resistive heater is disposed on a sleeve, the sleeveconcentric with the introducer sheath.
 7. The device of claim 6, whereinthe resistive heater is helically wound on the sleeve.
 8. The device ofclaim 1, wherein the ablation catheter further defines: a guidewirelumen; a supply lumen; and a return lumen.
 9. The device of claim 2,wherein the guidewire lumen extends from a proximal end of the ablationcatheter to a distal end of the ablation catheter.
 10. The device ofclaim 1, further comprising at least one marker band disposed on theablation catheter to locate a working region of the device at a desiredlocation.
 11. The device of claim 8, further comprising a source ofcryofluid having a supply tube and a return tube, the supply tubecoupled in fluid communication to the supply lumen and the return tubecoupled in fluid communication to the return lumen.
 12. The device ofclaim 11, wherein the cryofluid is a perfluorocarbon.
 13. The device ofclaim 12, wherein the cryofluid is Galden® fluid.
 14. The device ofclaim 11, wherein the cryofluid is DMSO.
 15. The device of claim 11,wherein the cryofluid is D-limonene.
 16. The device of claim 1, furthercomprising a gear pump for circulating the cryofluid.
 17. The device ofclaim 16, wherein the gear pump is one selected from the groupconsisting of a radial spur gear pump and a helical tooth gear pump. 18.A method of treating atrial fibrillation while preventing tissue damageto the atrial septum, comprising: inserting a trocar wire capable ofrupturing the atrial septum from the femoral vein into the right atrium;forming a hole using the trocar wire in the atrial septum between theright atrium and the left atrium; inserting an introducer sheath intothe hole, the introducer sheath at least partially contacting the atrialseptum; inserting a guide wire through the introducer sheath into theright atrium and left atrium and further into a pulmonary vein;disposing an ablation catheter over the guidewire into a volume definedby the joint of the left atrium and the pulmonary vein; flowing acryofluid into a balloon disposed within the ablation catheter to ablatetissue adjacent the joint of the left atrium and the pulmonary vein; andoperating and controlling a heater disposed adjacent or within theintroducer sheath, the heater thermally coupled to the atrial septum.19. The method of claim 18, wherein the operating and controlling aheater including providing power to a resistive heater.
 20. The methodof claim 18, wherein the operating and controlling a heater includesflowing a warming fluid into an inlet tube fluidically coupled to aninterior of the introducer sheath, and flowing the warming fluid out ofat least one outlet orifice disposed in the introducer sheath.
 21. Themethod of claim 18, wherein the operating and controlling a heaterincludes allowing a body fluid to flow in an inlet sleeve having aninput for the body fluid at a distal end of the introducer sheath,wherein the inlet sleeve is fluidically coupled to an interior of theintroducer, and allowing the body fluid to flow out of the at least oneoutlet orifice disposed in the introducer.
 22. The method of claim 18,wherein the cryofluid is selected from the group consisting essentiallyof Galden® fluid, DMSO, and d-limonene.
 23. The method of claim 18,further comprising circulating the cryofluid with a gear pump.
 24. Themethod of claim 23, wherein the gear pump is one selected from the groupconsisting of a radial spur gear pump and a helical tooth gear pump. 25.A method of performing a cryosurgery while preventing tissue damage tothe point of insertion, comprising: percutaneously forming an insertionhole in a vessel of a patient; inserting an introducer sheath into theinsertion hole, the introducer sheath at least partially contactingtissue at the insertion hole; inserting a cryogenic catheter through theintroducer sheath; disposing the cryogenic catheter at a predefinedlocation; flowing a cryogenic liquid into the cryogenic catheter; andoperating and controlling a heater disposed adjacent or within theintroducer sheath, the heater thermally coupled to the tissue at theinsertion hole.
 26. The method of claim 25, wherein the operating andcontrolling a heater including providing power to a resistive heater.27. The method of claim 25, wherein the operating and controlling aheater includes flowing a warming fluid into an inlet tube fluidicallycoupled to an interior of the introducer sheath, and flowing the warmingfluid out of at least one outlet orifice disposed in the introducersheath.
 28. The method of claim 25, wherein the operating andcontrolling a heater includes allowing a body fluid to flow in an inletsleeve having an input for the body fluid at a distal end of theintroducer sheath, wherein the inlet sleeve is fluidically coupled to aninterior of the introducer, and allowing the body fluid to flow out ofthe at least one outlet orifice disposed in the introducer.
 29. Themethod of claim 25, wherein the fluid is selected from the groupconsisting essentially of Galden® fluid, DMSO, and d-limonene.
 30. Themethod of claim 25, further comprising circulating the cryofluid with agear pump.
 31. The method of claim 30, wherein the gear pump is oneselected from the group consisting of a radial spur gear pump and ahelical tooth gear pump.
 32. A method of reducing atrial fibrillation,comprising: inserting a catheter at least partially into the heart, thecatheter having a cold balloon, a portion of the balloon located in theleft atrium and a portion of the balloon located in a pulmonary vein;and inflating the cold balloon with a working fluid including DMSO suchthat an exterior surface of the cold balloon is in contact with at leasta partial circumference of the portion of the pulmonary vein adjacentthe left atrium, the working fluid having a temperature in the range ofabout −10° C. to −100° C.
 33. The method of claim 32, wherein theworking fluid is circulated by a gear pump.
 34. The method of claim 33,wherein the gear pump is one selected from the group consisting of aradial spur gear pump and a helical tooth gear pump.
 35. A method ofreducing atrial fibrillation, comprising: inserting a catheter at leastpartially into the heart, the catheter having a cold balloon, a portionof the balloon located in the left atrium and a portion of the balloonlocated in a pulmonary vein; and inflating the cold balloon with aworking fluid including d-limonene such that an exterior surface of thecold balloon is in contact with at least a partial circumference of theportion of the pulmonary vein adjacent the left atrium, the workingfluid having a temperature in the range of about −10° C to −100° C. 36.The method of claim 35, wherein the working fluid is circulated by agear pump.
 37. The method of claim 36, wherein the gear pump is oneselected from the group consisting of a radial spur gear pump and ahelical tooth gear pump.
 38. A method of reducing restenosis afterangioplasty in a blood vessel, comprising: inserting a catheter into ablood vessel, the catheter having a balloon, the balloon having at leastone pore formed therein; and inflating the balloon with a working fluidincluding DSMO such that an exterior surface of the balloon is incontact with at least a partial inner perimeter of the blood vessel, theworking fluid having a temperature in the range of about −10° C. to−100° C.
 39. A method of reducing restenosis after angioplasty in ablood vessel, comprising: inserting a catheter into a blood vessel, thecatheter having a balloon, the balloon having at least one pore formedtherein; and inflating the balloon with a working fluid includingd-limonene such that an exterior surface of the balloon is in contactwith at least a partial inner perimeter of the blood vessel, the workingfluid having a temperature in the range of about −10° C to −100° C. 40.A device to perform a cryo-ablation treatment while allowing bloodperfusion, comprising: a catheter shaft having a supply lumen and areturn lumen; an annular ring balloon fluidically coupled to thecatheter shaft, the annular ring balloon having a fluid inlet coupled tothe supply lumen, and a fluid outlet coupled to the return lumen, thefluid inlet displaced relative to the fluid outlet, a plane of theannular ring balloon substantially normal to the catheter shaft wheninflated; and a source of working fluid, the source having an inletcoupled to the return lumen and an outlet coupled to the supply lumen.41. The device of claim 40, wherein the fluid inlet is displaced in aproximal direction relative to the fluid outlet.
 42. The device of claim40, wherein the source of working fluid includes a gear pump.
 43. Adevice to perform a cryo-ablation treatment while allowing bloodperfusion, comprising: a catheter shaft having a catheter supply lumenand a catheter return lumen; an annular ring balloon fluidically coupledto the catheter shaft, the annular ring balloon having a balloon supplylumen coupled to the catheter supply lumen, and a balloon return lumencoupled to the catheter return lumen, an inlet for the balloon supplylumen displaced relative to an outlet of the balloon return lumen, aplane of the annular ring balloon substantially normal to the cathetershaft when inflated; and a source of working fluid, the source having aninlet coupled to the catheter return lumen and an outlet coupled to thecatheter supply lumen.
 44. A method of reducing atrial fibrillation,comprising: inserting a catheter at least partially into the heart, thecatheter having an annular ring balloon disposed near a distal portionthereof, a portion of the annular ring balloon located in the leftatrium and a portion of the annular ring balloon located in a pulmonaryvein; and inflating the annular ring balloon with a working fluid suchthat an exterior surface of the annular ring balloon is in contact withat least a partial circumference of the portion of the pulmonary veinadjacent the left atrium, the working fluid having a temperature in therange of about −10° C. to −100° C.
 45. The method of claim 44, whereinthe working fluid is selected from the group consisting essentially of:DMSO, d-limonene, Galden fluid, and a perfluorocarbon-containing fluid.46. The method of claim 44, wherein the inflating includes circulatingthe working fluid with a source of working fluid having a gear pump. 47.A method of providing a prophylactic therapy against atrialfibrillation, comprising: performing a cardiac surgical procedure;inserting an ablation catheter at least partially into the heart, theablation catheter having a balloon, a portion of the balloon located inthe left atrium and a portion of the balloon located in a pulmonaryvein; inflating the balloon with a cryogenic working fluid such that anexterior surface of the balloon is in contact with at least a partialcircumference of the portion of the pulmonary vein adjacent the leftatrium, the working fluid having a temperature in the range of about−10° C. to −100° C.
 48. The method of claim 47, wherein the cardiacsurgical procedure includes valve replacement.
 49. The method of claim47, wherein the cryogenic working fluid is selected from the groupconsisting essentially of: DMSO, d-limonene, Galden fluid, and aperfluorocarbon-containing fluid.
 50. The method of claim 47, whereinthe inflating includes circulating the working fluid with a source ofworking fluid having a gear pump.
 51. The method of claim 47, whereinthe balloon has at least one pore formed therein.
 52. The method ofclaim 47, wherein the balloon is an annular ring balloon.
 53. The methodof claim 47, further comprising: inserting a trocar wire capable ofrupturing the atrial septum from the femoral vein into the right atrium;forming a hole using the trocar wire in the atrial septum between theright atrium and the left atrium; inserting an introducer sheath intothe hole, the introducer sheath at least partially contacting the atrialseptum; inserting a guide wire through the introducer sheath into theright atrium and left atrium and further into a pulmonary vein;disposing the ablation catheter over the guidewire into a volume definedby the joint of the left atrium and the pulmonary vein; and operatingand controlling a heater disposed adjacent or within the introducersheath, the heater thermally coupled to the atrial septum.
 54. Themethod of claim 47, further comprising: percutaneously forming aninsertion hole in a vessel of a patient; inserting an introducer sheathinto the insertion hole, the introducer sheath at least partiallycontacting tissue at the insertion hole; inserting the ablation catheterthrough the introducer sheath; disposing the ablation catheter at apredefined location for an ablation therapy; and operating andcontrolling a heater disposed adjacent or within the introducer sheath,the heater thermally coupled to the tissue at the insertion hole. 55.The device of claim 12, wherein the cryofluid has been substantiallypurged of dissolved gases.
 56. The method of claim 18, wherein theflowing further comprises purging the cryofluid of dissolved gases. 57.The method of claim 56, wherein the purging includes: diffusing a gasinto the fluid for a period of time; and de-pressurizing an environmentadjacent the fluid such that at least a partial vacuum is achieved. 58.The method of claim 57, further comprising agitating the fluid during atleast one of the diffusing and de-pressurizing.
 59. The method of claim58, wherein the agitating includes stirring.
 60. The method of claim 57,wherein the diffusing occurs for a period of time of between about 20and 30 minutes.
 61. The method of claim 57, wherein the de-pressurizingoccurs for a period of time of between about 5 and 10 minutes.
 62. Themethod of claim 57, wherein the gas is USP grade or better of helium.63. The method of claim 57, wherein the partial vacuum is between about15″ to 20″ of Hg.
 64. The method of claim 63, wherein thede-pressurizing occurs for a period of time of about 5 minutes.
 65. Themethod of claim 57, wherein the diffusing and de-pressurizing areperformed within a continuously circulating source of working fluid. 66.The method of claim 65, further comprising sensing a presence ofdissolved gases during the circulating with an in-line gas sensor.
 67. Amethod of preparing a carbon-containing fluid for a biomedical use,comprising: diffusing a gas into a carbon-containing fluid for a periodof time between about 20 and 30 minutes; and de-pressurizing anenvironment adjacent the fluid such that at least a partial vacuum isachieved for a period of time between about 0 and 10 minutes.